Lecture topic Lecture # 1st view Annotation Review Rereview

Emergency 1 2017-04-18 2017-04-18

Emergency I
I. Vomiting and diarrhoea
A. Differential diagnoses that need to be
excluded
1. Obstruction
- Intussusception
- Appendicitis
- hernia

2. infection
- UTI / meningitis / gastroenteritis

3. Metabolic conditions
- DKA
- HUS

4. Neurological
- Increased ICP?

B. History: to delineate the above DDx

- abdo pain / distension
- bile
- high fevers
- polydipsia, polyuria, wt loss
- headache - raised intracranial pressure

C. History/evaluation:
1. assessment of hydration
(a) fluids in:
- as a fraction of normal
(b) fluids out:
- wet nappies
- >8hours = red flag
- diarrhoea / vomiting

ii WHO dehydration scale

mild (5%)
- mild tachy, low urine o/p
moderate (7-9%)
- lethargy
- sunken eyes / fontanelle
- \/ skin turgor
severe (>10%)
 - altered LOC
- signs of shock

D. Treatment
i mild dehydration
- frequent small volumes of fluids
- oral fluids!
- milk, gastrolyte.
- don't use orange juice (pulp causes vomiting)
- if not tolerated
- NG
- IV fluids
ii dystonic reaction
- prochloperazine, metoclopramide
- ondansetron is safest
- most common in <2 but can happen upto 11y.o.
therapy by age
baby (<12/12)
- anticholinergic antihistamine
- diazepam
infant (>1yr)
- Benztropine

II. Febrile child

- Points to rule out:
- bacteraemia?
- shock
- toxin: endo/exotoxaemia

A. diagnosis febrile convulsions

febrile convulsion
- 2-5% of kids
- family Hx
- not indicative of epilepsy (only 2-3% chance (double baseline) of developing epilepsy)
- do have /\ risk of recurrent febrile convulsions!
simple vs complex
- occur w/ fever
- fever may be apparent post seizure
- generalised
- whole body
- no focal activity
- brief (<5min)
- only 2-3h of post-ictal issues
- no residual neurological sequalae
complex if not the above

B. History
- irritable vs consolable
- localising symptoms

C. Evaluation – need to rule out bacteraemia

bacteraemia / sepsis: [NOT ALS APPROACH!]
(a) A - airway
(b) B - breathing
- effort
(c) C - circulatory impairment
- cap refil!!
- BP, hear rater
(d) D - disability
- AVPU
- P= GCS of 9

**no sign in isolation, absence of a sign doesn't exclude**

D. Treatment
1. bacteraemia
- t/f to hospital

i if meningococcal suspected:
- petichae = tiny areas of disseminated intravascular coagulation (DIC) in skin
- will grow - coalesce - pupura
(a) IM benzylpenicillin
- 300mg baby (<1yr)
- 600mg infant/child (1-9yrs)
- 1.2g 'adult' (includes child >10yrs)
(b) ceftriaxone
- 50mg/kg - up to 2g (for 'adults' or teens only)
(c) chemoprophylaxis for family:
- ceftriaxone / ciprofloxacin / rifampicin